Lower Limb Orthotics: Distal to knee quiz 1

True/False: Only 1 out of every 10 people in need of P&O services have access to them

True

What percentage of an orthotists time is spent on lower limb orthotics?

59%

What are the two problems with eponyms?

1. They don't define a site of application or indication of function2. Terminology is illogical and can only be learned by role memorization

What were the main goals of the "Nomenclature task force"?

-Develop terminologies based on logical systems (but needs to be flexible enough to accept new devices)-Allow physician/O&P communication-Logical system for teaching-Development of fee-paying schedules-Authority list for information retrieval (standardized componentry and outcomes)

What is the definition of a "free"?

Free motion

What is the proper nomenclature of the component that follows: "Application of an external force for the purpose of increasing the range, velocity or force of a motion

Assist

What is the proper nomenclature of the component that follows: "Application of an external force for the purpose of decreasing the velocity or force of a motion

Resist

What is the proper nomenclature of the component that follows: "Inclusion of a static unit to deter an undesired motion in one direction

Stop

What is the proper nomenclature of the component that follows: "A unit that can be adjusted without making a structural change

Variable

What is the proper nomenclature of the component that follows: "Elimination of all motion in the prescribed plane

Hold

What is the proper nomenclature of the component that follows: "Device includes an optional lock

Lock

What are the 3 main clinical considerations for an AFO?

Age, Ambulatory, Non-ambulatory

Why might thin, low temperature plastics be preferable for infants/toddlers?

They can get a noxious stimulus from over touching, so the low temp thermoplastic will be faster to get them out quick. Also these children change so fast, that a week of cast modification could end up with a poor fit.

What is the main consideration for child/teen age patients?

Keeping up with peers

Why is the life of an orthosis more important in young adults and adults than in children?

There is no longer rapid growth, so one orthosis will fit longer than children who grow out of it so quickly.

What should you be looking for when observing gait deviations?

Primary cause and secondary compensatory mechanisms

True/False: The goal of lower limb orthoses is to return the patient back to normal gait

False, functional may be the goal and that can be hard to explain to the family

What are the 4 considerations for a non-ambulatory patient?

1. Positional2. Balance3. ADLs4. Cognition

What happens to a sitting knee flexion contracture during ambulation? What is the impact of this?

It doubles, and that results in an O2 rate of consumption and cost increase

What are the 5 purposes of the foot?

1. Acts as a support base that provides the necessary stability for upright posture with minimal muscle effort2. Provides a mechanism for rotation of the tibia and fibula during stance phase of gait3. Provides flexibility to adapt to uneven terrain (Subtalar joint)4. Provides flexibility for absorption of shock5. Acts as a lever during push-off (3rd/4th rocker)

What are the two joints that sagittal plane dorsiflexion/plantarflexion occur?

Ankle and Chopart joints

What joint is responsible for the coronal plane inversion/eversion (Varus/Valgus) of the ankle?

Subtalar joint

What is/are the other name(s) for the Chopart joint?

Oblique Midtarsal Joint Axis (OMJA) or Transverse tarsal joint

What is/are the other name(s) for the Lisfranc joint?

Tarso-Metatarsal Joint (Tarsometatarsal joint)

In what plane do adduction and abduction of the foot occur? And what joint is responsible for this movement?

Transverse plane; OMJA

Describe the position of supination of the foot and ankle.

Plantarflexion of the talocrural joint, adduction of the forefoot, and inversion of the subtalar joint

Describe the position of pronation of the foot and ankle.

Dorsiflexion of the talocrural joint, abduction of the forefoot, and eversion of the subtalar joint.

What is closed kinetic chain?

When the foot is on the ground (Stance phase)

What is open kinetic chain?

When the foot is off the ground (Swing phase)

What bones make up the hindfoot/rearfoot?

Talus and Calcaneus

What bones make up the midfoot?

Navicular, cuboid, and the cuneiforms

What bones make up the forefoot?

metatarsals and phalanges

What bones make up the medial column of the foot? And what is the main function of the medial column of the foot?

-Talus, navicular, cuneiforms, MTP 1-3-This column is most effective at attenuating shock

What bones make up the lateral column of the foot? And what is the main function of the lateral column of the foot?

-Calcaneus, cuboid, MTP 4-5-This column is rigid and enables propulsion

What percent of the compressive loads is the medial column of the foot responsible for?

70%

What percent of weight bearing through the shank is the tibia responsible for? And the fibula?

-Tibia = 83%-Fibula = 17%

Which bone of the ankle is considered the "mechanical keystone" and does not have any muscle attachments?

Talus

How does the calcaneus act as a force amplifier for plantarflexion?

Insertion of achilles tendon is further away from the talocrural joint axis

What passes through the cubital notch/Peroneal sulcus?

The fibularis longus tendon

What are the normal and functional ranges of motion for the talocrural joint?

Normal - 20 deg of DF/50 deg of PFFunctional - 10 deg of DF/20 deg of PF

What is the functional range of motion for the subtalar joint? And what is the main purpose of the subtalar joint?

ROM: 4-6 deg of inversion/eversionAdapts to uneven terrain

What is the effect on the midfoot/forefoot if the hindfoot is inverted/varus or neutral? What is the functional benefit of this?

The midfoot and forefoot are rigid, which enables push off

What is the effect on the midfoot/forefoot if the hindfoot is everted/valgus? What is the functional benefit of this?

The midfoot and forefoot are flexible, which enables shock absorption

What position do the calcanealcuboid and talonavicular joint axes need to be in to enable propulsion?

They need to be crossing, which is in supination or neutral alignment

What position do the calcanealcuboid and talonavicular joint axes need to be in to enable shock absorption?

They need to be parallel, which is in pronation

What joint axis is perpendicular to the OMJA? What does this permit?

The longitudinal midtarsal joint axis (LMJA) and this permits triplanar movement across the midtarsals

What type of joint is the tarsometatarsal joint?

Plane (gliding)

What type of joint is the MTP joint?

Condyloid

What is the common name for the plantarcalcanealnavicular ligament?

Spring ligament

What ligament is responsible for maintaining the medial longitudinal arch? What other benefit does that ligament have?

Deltoid ligament; prevents excessive eversion

What is the windlass mechanism?

When the toes are extended, the medial LA raises, and the distance from heel to MTP shortens

What muscles make up the anterior compartment of the shank and what is their innervation and action?

-Tibialis anterior, extensor digitorum longus, extensor hallucis longus-deep fibular nerve-dorsiflexors

What muscles make up the lateral compartment of the shank and what is their innervation?

-Fibularis longus, fibularis brevis-superficial fibular nerve

What muscle attaches to the base of the 1st MT and is responsible for plantarflexing the first ray when the foot is in varus/inversion or neutral alignment?

Fibularis longus

What muscles make up the superficial posterior compartment of the shank and what is their innervation and action?

-Gastrocnemius, soleus (Triceps surae)-tibial nerve-plantarflexors

What muscle of the posterior compartment is mainly for postural support and is most active in standing?

Soleus

What muscles make up the deep posterior compartment of the shank and what is their innervation and action?

-Tibialis posterior, flexor digitorum longus, flexor hallucis longus (Tom Dick and Harry)-Tibial nerve-weaker plantarflexors

What is the role of tibialis posterior during gait and where is its distal attachment?

-It creates stability of the medial LA, during early stance it controls the arch and acts for shock absorption-Attaches to the apex of the navicular

What position is the hindfoot in during initial contact? What is the benefit of that?

Hindfoot everts, which makes the OMJA flexible to attenuate shock

What phase of gait does the foot become rigid to enable propulsion?

Terminal stance/preswing

What is the clinical presentation of 1st ray insufficiency?

-Lack of callus under 1st met head-callus under 2nd met head-increased risk of 3rd, 4th and 5th met head callus formation-pronation is common

What are common complications of 1st ray insufficiency?

-Hallux valgus (bunyion)-midfoot arthritis-metatarsalgia-plantar plate injury-lesser metatarsal stress fractures-hammer toe

What test is used to assess for 1st ray insufficiency?

Dynamic Hicks Test (Also modified Klaue device?)

What orthotic intervention(s) is/are used for 1st ray insufficiency?

-Morton's Extension-foot orthosis-ucbl

What is the grading scales/classification for metatarsus adductus?

-Heel bisector method-Berg classification

What orthotic interventions can be used to treat metatarsus adductus?

-Straight last shoes-reverse last shoes-Bebax boot-Wheaton KAFO/AFO

What are the two types of pes planovalgus? How do they present?

Flexible - collapsed medial LA during weight beating, but neutral when on toesRigid - flat foot, but could be due to tarsal coalition or contracture

What are the diagnostic techniques used for pes planovalgus?

Feiss line, Meary's angle

What are the orthotic treatments that can be used for pes planovalgus?

-Foot orthosis or UCBL

How does talipes equinovarus present?

Pes cavus, adduction of the forefoot, hindfoot varus, and ankle equinus

What pathology is the Pirani score used for?

Talipes equinovarus

What are the possible orthotic treatments for talipes equinovarus?

-Ponsetti method (most common)-straight last shoes attached to a FAB:--Dennis brown bar--horton click--Dobbs--Ponsetti

What is the clinical presentation of peroneal nerve palsy?

Foot drop, high steppage gait, numbness on dorsal side of foot, atrophy of mucles, pain

What is the orthotic treatment recommendation for peroneal nerve palsy?

-AFO (PLS or dorsiflexion assist)-Functional electrical stimulation

What type of arthritis is considered to be "wear and tear"?

Osteoarthritis

What is the presentation of osteoarthritis?

Pain in 1st MTP joint, midfoot pain, medial LA collapse, forefoot abduction, joint swelling, warmth and redness, difficulty walking

What pathology is the kellgren and lawrence classification system applicable to?

Osteoarthritis

What are the possible orthotic interventions for osteoarthritis?

-Cushioned heel-Foot orthosis with LA support-Stiff sole with rocker bottom-Arizona AFO

What is the clinical presentation of rheumatoid arthritis?

Swollen joints, joints are sensitive and warm, high levels of fatigue, affects smaller joints first, usually B/L

What are the different aspects of rheumatoid arthritis you look for in a clinical evaluation?

-RA nodules at met heads-RA nodules on heel-hallux valgus-redness-swelling-hammer toes-callusing-ulceration

What is the grading scale for rheumatoid arthritis?

AIMS2 - SF

What are the possible orthotic interventions for rheumatoid arthritis?

-Extra depth shoes-Extra wide shoes-custom shoes-FO-compression socks

True/False: The knee joint axis and the talocrural joint axis are parallel

False, the talocrural joint is 20-30 deg externally rotated

What phase of stance gait is the maximum amount of dorsiflexion occurring?

The end of midstance and beginning of terminal stance (10 deg)

What phase during stance gait is the maximum amount of plantarflexion occuring?

loading response (20 deg)